Women's Perceptions of Midwife Led Care

The Family Birth Centre (FBC) is a midwife-led unit offering woman centred care to low risk women and is adjacent to King Edward Memorial Hospital (KEMH), the only tertiary maternity hospital in Western Australia. The underpinning philosophy of the midwives working in the FBC is to empower women to make informed choices about their care, with a focus on enabling them to labour and birth with minimal intervention. Women are allocated to a group of five midwives at their booking visit and subsequently meet the other midwives in the group during the course of their pregnancy visits and classes. Midwives at the FBC practice in collaboration with other healthcare professionals; any deviation from normal progress results in referral to the general practitioner, obstetrician, physiotherapist or clinical psychologist.

In many areas of the world, midwives are the primary care providers of maternity care. Women receiving midwifery care benefit from many positive outcomes including a reduction in intervention and operative vaginal birth (Hatem, Sandall, Devane, Soltani, & Gates, 2008); however, in Western Australia this model of care is less common. Home-like facilities have been demonstrated to be preferred by women (Hodnett, Downe, Edwards, & Walsh, 2005; Overgaard, Fenger-Gron, & Sandall, 2012) and support from a known person has been found to facilitate normal labour (Hodnett, Gates, Hofmeyr, & Sakala, 2007). The aim of this project was to determine women's views around the care they received in the FBC whilst providing the opportunity to voice concerns as a feedback mechanism to improve the quality FBC care.

Family Birth Centre Evaluation

A questionnaire was designed and sent (using SurveyMonkey TM) to 290 women post birth, who were booked to birth at the FBC from June 2012 to April 2012. The project was approved by the Women's and Newborn Health Service Audit Committee and subsequently supported for publication by the Human Ethics Committee at KEMH.

Results

An initial population of 290 women were approached via email. However, 16% (47 out of 290) had an invalid email address and could not be contacted. Of the 243 women with a valid email address 43% (105 out of 243) completed the questionnaire. Women became aware of the FBC through friends and family 48%, (n = 50), the internet 20%, (n = 21), or their General Practitioner 12%, (n = 13). The majority of women (69%, n = 72) birthed at the FBC with 31 % (n = 33) transferred to KEMH for their birth and one woman birthing at home. The overwhelming majority of women (95%, n = l00) expressed a preference to book at the FBC for their next birth. Women's confidence in their midwives was high (97%, n = 102). Having a known midwife for their birth was important for 73% (n = 77) of women, so it was encouraging that 82% (n = 86) were cared for in labour by a midwife from their midwifery team. During labour the majority (98%, n = 103) of women wanted to feel they were in control. Post birth women felt they received the help they required (95%, n = 100), especially in relation to breastfeeding support (94%, n = 99) (see Table one, below).

Thematic Analysis

Women were encouraged to provide further comments and thematic analysis was conducted to extract common themes, patterns and similarities from their responses. A total of 98 women provided comments. Quotes from these women are offered to support the themes and subthemes with a labelling system (p. 1-p. 105) for individual women's responses.

Positive Birth

Having a positive birth experience was dependent on a number of distinct sub-themes. These included: being treated as an individual; having a known midwife; birthing in a homely environment; being in control; being well informed; and knowing the hospital was close by. These sub-themes were encased by an encircling theme of warm and experienced support and midwifery care (Figure 1).

Treated as an Individual

Being treated as an individual was important and involved being "accepted and supported with the choices I made.”( p.102), others loved the fact that the care was "client led the ability for us to make decisions on the type of birth that we would like" (p. 79) and "they let me make choices about the labour and supported those choices." (p. 20). Women felt especially valued when they were listened to "My midwife was amazing. I had a long labour ... as I did hypnobirthing I think I went in thinking it would be easy but by the end I really didn't think I could do it and was asking to go to the hospital - my midwife listened to me and asked if that's what I wanted she would make it happen. Just the fact she was listening to me, I believe relaxed me enough that my baby came very soon after.“ (p. 32).

Well Informed

Women perceived that being informed involved being given "enough information to make really informed decisions, by midwives I trusted" (p. 67) and "very; attentive midwives, made decisions easier knowing we were given all the information required to make them from an experienced team." (p. 43). Information empowered women to make decisions regarding their care "very supported by the midwives and provided with good information to make informed decisions. I felt that my opinions were always respected." (p. 16). One women felt it was important that she "well informed and was never pressured on any decisions" (p. 52). The information imparted enabled women to plan their birth “I really like that I was given all the information I needed to make a decision as to what type of birth I wanted and that the birth centre facilitated my wishes perfectly." (p. 85).

In Control

The overwhelming majority of women commented on the benefit of "feeling involved in my birthing experience, being informed and in control" (p. 94). Women linked the care they had received from their midwife to a feeling of empowerment and being in control, one woman stating “I absolutely loved my midwife - she made me feel confident and relaxed. I felt I could birth the way I wanted to birth, in tire most comfortable position for myself I felt very much in control" (p. 45). Another had the insight to acknowledge that "I felt very supported by the midwife but ultimately I was in control, which is a fantastic feeling especially after the birth ... you think, 'wow I did that all by myself!!!' It was awesome, I got the exact experience I wanted, relaxed environment, water birth, no drugs, no stitches ... and no swearing!!! Thank you so much!" (p. 25).

Homely Environment/Hospital Was There

The homelike environment of the birth centre helped relax women "I just liked the fact I could use the birth centre and not a hospital, l was able to relax more" (p. 11). Many found it very reassuring to know that the hospital was close by in case any problems rose "I felt empowered and supported. I chose FBC because I wanted to have the option of water birth and I wanted midwife care so that interventions would be less likely. I felt confident with KEMH obstetricians available in case of any emergencies/complications" (p. 13) and "100% access to full medical care while birthing in a low key environment" (p. 21) also the “atmosphere - having a 'home-birth' with the back-up and support of the main hospital" (p.79). Although women believed in their body's ability to birth naturally they were reassured by knowing help was close by "I was supported in my belief that my body knows how to birth but having professional caring support from a midwife, and emergency back-up to alleviate fear of things going wrong" (p. 27).

Known Midwife

It became clear that "seeing the same midwives for my antenatal appointments" (p. 23) and "the fact that the midwife from the birthing centre still delivered my baby even though I was transferred to the hospital" (p. 101) was important for women. The "ability to meet the midwives from the team in advance of the delivery” (p. 93) was appreciated. One woman highlighted that "although I ended up at the hospital, during the course of the birth. I had three midwives from the birthing centre with me. Two of which I find met and one who was new. This made me feel more relaxed" (p. 75).

Midwifery Care

Midwifery care was perceived as a core component of having a positive birth. Women clearly appreciated that "the midwives always put me and my baby first" (p. 12) highlighting the philosophy of woman-centeredness at the FBC. Midwifery care was perceived to be supportive "excellent midwifery care and support. Relaxed, non-medicalised atmosphere" (p. 86) and "the very supportive, caring and understanding nature of all the midwives. They were able to listen and understand where I was coming from" (p. 76). This attribute was especially important for one woman who stated "I did not have a support person and had to stay at the FBC for three days. I absolutely loved the friendliness and warmth of nil the midwives.... I honestly felt loved and valued upon leaving." (p. 96). Receiving "warm and experienced support from tile midwives at the birthing centre" (p. 17) helped another woman to "make everything seem normal and not scary" (p. 34). Having "24/7 access to midwives and their advice. I never had to worry about my pregnancy because they were monitoring me and I could call them anytime was reassuring" (p. 96). Women continually described how they felt cared for "I was both comforted and thrilled to be cared for by such a dedicated and knowledgeable group of midwives. Completely exceeded all my expectations" (p. 84) and "I had a wonderful experience at the FBC. The midwives were competent, supportive, honest, and caring" (p. 27). Finally women described their midwife as if they belonged to them "our midwife was fantastic and came with us to the hospital. She really took the lime to help give us an excellent birth, as close to our birth plan as possible, even though we had to be transferred" (p. 100).

Discussion and Conclusion

The overwhelming theme that emerged from this evaluation was the importance of midwifery care to women throughout the continuum of antenatal, labour and postnatal care. Kennedy suggests that excellence of midwifery care may be due to the knowledge of the normal physiological process and ability to 'do nothing' with vigilance and attention to detail (Kennedy, 2000). The Cochrane Review in 2008 (Hatem, et al. 2008) found that midwife-led care was associated with several benefits for women, including one mentioned several times by FBC women; the feeling of being in control.

Our study clearly demonstrates that women appreciate the midwife's belief in their ability to give birth but also rated their experience, expertise and ability to make the right decision at the right time very highly. These findings reinforce the fact that women want to be cared for by a midwife with a philosophy for woman centred care, who listens to the woman's informed choice and draws on her own knowledge and experience to ensure the best outcome for the woman and her baby.

Originally published in ‘Midwifery News’ Spring 2013 Pages 24-26. Publication of the Australian College of Midwives www.midwives.org.au